Tuesday, 19 August 2008

I was listening to radio 5live on the drive home from work yesterday afternoon and they were interviewing Dave Brailsford, the man who is the head of British Cycling about the absolutely phenomenal achievement of the track team in Beijing (7 gold medals from 10 events so far!). Dave was explaining how the cycling team had gone about targeting every single aspect of the performance of the riders and the bikes and really left no stone unturned in their meticulous preparation. The quote that he came up with was “In order to improve things by 100%, you need to improve 100 things by 1%.”

This struck a cord with me and my work in the NHS. The NHS has far, far more money than British Cycling (in fact, the entire annual budget for British Cycling would run the NHS for about ten hours) but in 2008, we are struggling to provide the sort of world class service that we aspire to. It’s a little allegorical to what I wrote about the real difference between ICU and ward care.

I’ve been reading the posts of Dr Jane Doe over at Two Weeks On A Trolley with great interest. She’s been pointing the inefficiencies in the Irish Healthcare system (for Irish, read British because, at the front line, the two systems are pretty identical) and how these inefficiencies directly compromise patient care. She also writes about how the healthcare system down under copes with exactly the same problems in a much better, faster, more efficient and cheaper way. You really should read her posts, they’re fantastic.

I think part of the problem with the NHS is that nobody listens to the people who actually deliver the service. Actually, it’s not even that nobody listens, nobody evens asks the questions. Nobody wants to hear our ideas about how we can make the service better, and that is one of the most frustrating things.

Anyway, this post isn’t meant to be just another “The NHS is crap” whine, I actually wanted to write something constructive about how I think my area of specialty (anaesthesia) could be improved. Here are my top 5 ideas:

1. Get rid of the anaesthetic room.

The anaesthetic room (AR) is an anteroom right next to operating theatre. Patients coming in for surgery come into this room where we anaesthetists give them their general anaesthetic before moving the unconscious patient into the operating room (OR). From day 1 as an anaesthetist, I’ve always thought that this was really pointless. The hardest part of a general anaesthetic is the induction. This is the time where the patient is the most unstable, and as a result, this is the time that the patient is the most vulnerable. To me it seems really odd that, at the time where the patient is most at risk, we have to disconnect all our monitoring equipment and then move the patient into the OR and then drag the (sometime quite hefty) patient from the trolley onto the operating table. It’s all totally pointless and unnecessary. It puts the patients at risk and it puts the staff at risk too from having to drag unconscious people around. It would make much more sense to have the patient walk into the OR and then we give them their anaesthetic on the operating table – in fact this is exactly what we do if we feel the patient is a particularly high risk (e.g. emergency AAA repairs).

2. Automatic DoorsAs I said above, we anaesthetist spend a lot of time moving unconscious people around. We go from the AR to the OR and from the OR to the recovery room. Some times we have to go through three or four sets of double doors wheeling an unconscious person on a trolley. We do this several times a day. Having to open doors and hold them open when we’re transferring patients is a pain in the arse. Can we not have automatic doors in theatres? If not fully automatic, then at least the type that open when you push a button. It makes sense. They have them in just about every high street store, can we not have them in the NHS?

3. Printouts

During an operation, we anaesthetist keeps a record of the patient’s vital signs. Every five minutes, we’ll write down the patient’s blood pressure oxygen saturations etc… etc… Whilst this is no big chore, it surprises me that the highly expensive anaesthetic machines just can’t print all this information out for us. Surely it can’t be that difficult?

4. Use Wireless Technology

I can sit and type this on my laptop and publish it to the internet using no wires at all. Bluetooth means that we can connect our mobile phones to our fridges if we so desire. As an anaesthetist, I spend a lot of my time untangling the patient from the wires and cables of our monitoring devices. The ECG leads, blood pressure tube and sats probe will inevitably get wrapped around or caught under various parts of the unconscious patient. We should be able to have ECGs, BP cuffs and sats probes that connect to the anaesthetics machines wirelessly and get rid of this problem.

5. Bleeps

This is one that’s not specific to anaesthesia but is the bane of junior hospital doctors across the nation. The bleeps (or pagers) that we have to carry and use to contact each other have to be the most annoying and inefficient way of communicating ever invented. I’ve mentioned this before and the solution is for hospitals to have a mobile phone system rather than a paging system. Communication would be much better and things would get done faster because staff won’t have to sit around waiting for people to answer their bleeps.

6 comments:

I agree that we have a real problem in this country of asking people who work in a particular field/area what changes they think could be made that would make things better. That is because we have learnt to rely on management consultants by following American trends. Everything seems to be great if a firm of consultants suggests it, but rubbish if it comes from the workforce. Your suggestions for how you would improve things in your area of expertise is interesting, and in the main very sensible. However, I do have some concerns about your first suggestion, that of patients walking into the operating theatre. I would be totally incapable of doing that because I get so worked up before having an operation, that I generally require some form of sedation to settle me down. The last thing that I would want to see is the inside of the operating theatre.

I quite like anaesthetic bays. I take the points you raise but I don't think I'd like to walk into a theatre stone cold sober and hop up onto a table. I'd like to be all Midazolamed up. Not only that but there are so many hazards in a theatre, you just need one patient to slip over in their bare feet/slippers and Elf n Safety would have your guts for garters.

On the printout point, some anaesthetic machines have a facility for attaching a printer so you can wait till the end of the case then print out all your obs. I suppose it's a money thing for individual Trusts.

Cordless monitoring would be an absolute winner. Maybe you could invent some then sit back and wait for the money to flood in!

Thanks so much for the kind words, michael! I love your blog, it's awesome to get a mention!This inefficiency really seems to be a Northern hemisphere thing, doesn't it? They are not open to the idea of change, unlike down here-the other day the surgical dept were talking seriously about giving everyone PDAs and doing discharges on your PDA from a remote location-and everyone was seriously considering it. So different to home-they are so willing to try new things to improve things here and they embrace technology.

This made me laugh. Come do anaesthetics in NZ - we have no anaesthetic rooms (just tell the nurses to be quiet during induction, if pt nervous premed them in preop), big buttons on the walls at foot height to kick to open doors, automated "Safer sleep" computers attached to anaesethetic machine (records data and has barcode scanner for drugs etc) and mobile phones throughout the hospital...